1. Lyme Disease in NH: 2011 Update Jodie Dionne-Odom, MD Deputy State Epidemiologist Division of Public Health Services, DHHS Section of Infectious Disease Dartmouth Medical School

2. Outline History Tick Biology and Ecology Surveillance National and Local Epidemiology Clinical Manifestations Management Prevention

3. US HISTORY

4. Lyme Disease First recognized US 1975 –Many juvenile rheumatoid arthritis cases around Lyme, CT –In Europe, similar skin rashes and meningopolyneuritis described for 100 years. In 1983, both syndromes linked after recovery of the spirochete in a patient.

5. THE ORGANISM

7. Biology of Lyme Disease This bacteria is difficult to culture. Extracellular pathogen B. burgdorferi is carried by ticks. –Vector = Ixodes Lyme disease is now the most common vector-borne disease in the US and Europe.

8. Geography Worldwide in temperate zones: – North America Northeast: Maine to Maryland Mid West: Wisconsin and Minnesota West Coast: California and Oregon –Europe (forested areas) – B. garinii – Northern Asia

9. THE VECTOR (bug warning)

12. American dog tick = Dermacentor variabilis

14. Dog Ticks (aka Wood Ticks) American dog tick Photo credit: U of MN Entomology Dept.

16. The Life Story of Ixodes scapularis Larval, nymph and adult stages. 1.Adults peak in spring and fall – preferred host is white-tailed deer. Mating occurs. 2.Nymphs peak May-July – aggressive - frequently bite humans 3.Larvae peak August-September (from eggs on the ground)

18. Reservoir Hosts Deer, wild rodents, and other animals –White-footed mice are preferential hosts for larval and nymphs (Mice maintain spirochetemia)

19. SURVEILLANCE

20. Case Classification 2011 Confirmed: a) case of EM with a known exposure b) case of EM with laboratory evidence of infection c) a case with at least one late manifestation with lab evidence of infection. Probable: case of physician-diagnosed Lyme disease with lab evidence of infection Suspected: a) a case of EM with no known exposure or lab evidence of infection b) a case with lab evidence of infection but no clinical information.

21. Surveillance Case definition 2011 Laboratory criteria for diagnosis 1.Positive Culture for B. burgdorferi 2.Two-tier testing interpreted using established criteria: 1.ELISA, then Western Blot (IgM and IgG) 3.Single-tier IgG immunoblot seropositivity using established criteria. 4.CSF antibody positive for B. burgdorferi

22. US EPIDEMIOLOGY

25. NH EPIDEMIOLOGY

26. Lyme Disease Surveillance in NH Reportable in NH since 1990 1991-1999: 15-47 cases per year Increasing incidence began in 2000 –124 cases in 2000 –1,621 cases in 2008 (peak) 2 nd most common reportable infectious disease

27. Annual Incidence of Reported Lyme Cases in NH, 1991-2006

29. Highest Incidence States, Selected Years, 1992-2009 Year1 st 2 nd 3 rd 1992Connecticut (Rate: 53.7) Delaware (Rate: 31.7) Rhode Island (Rate: 27.5) 2000Connecticut (Rate: 104.8) Rhode Island (Rate: 64.2) New Jersey (Rate: 29.2) 2008New Hampshire (Rate: 92.0) Delaware (Rate: 88.4) Massachusetts (Rate: 60.9) 2009Delaware (Rate: 111.2) Connecticut (Rate: 78.2) New Hampshire (Rate: 75.2)

30. Reporting Process In 2006, all reported cases were assigned to a public health nurse for investigation –Called provided to collect symptom, treatment, and exposure information >100% increase in 2006 –271 cases in 2005 vs. 617 cases in 2006 In 2007, a letter system implemented to reduce burden to public health staff –Collected surveillance data via form mailed to all providers ordering a Lyme disease test with a positive result

31. 2010 Lyme Disease Investigations A total of 2,002 Lyme disease reports received 826 (41%) Confirmed 509 (25%) Probable 175 (9%) Suspect (missing information) 492 (25%) did not meet case definition

32. Data including 2010

35. NH LYME MAP 2002-2010

45. Active Surveillance for Borrelia in New Hampshire Deer Ticks Fall 2007, Fall 2008, and Fall 2009 deer ticks were collected from all ten NH counties Ticks were tested for presence of Borrelia burgdorferi by PCR Fewer than 20 ticks were collected from 4 counties and data could not be analyzed Overall state proportion of ticks infected was 60% (686 of 1,140 ticks collected) Babesia and Anaplasma also detected at lower rates (<10%) though testing not complete

46. 2007- 2009 Fall Tick Collections

47. 2007- 2010 Fall Tick Collections

49. *Rate per 100,000 persons

52. Coinfections Disease20062007200820092010 Anaplasmosis03141819 Babesiosis338710 Ehrlichiosis31766

53. NH Surveillance Data on the Web Maps Data Reports Incidence by County http://www.dhhs.nh.gov/dphs/cdcs/lyme/p ublications.htm

54. CLINICAL DISEASE

55. Lyme Disease - Clinical Features (2) Incubation : 3 to 32 days Early localized disease within 1 month of infection Slowly expanding skin lesion (80%): erythema migrans rash Usually accompanied by influenza-like illness:headache, arthralgias, myalgias, fever, lymphadenopathy.

61. Lyme Disease - Clinical Features (3) Early disseminated disease –Weeks to months after initial infection –Can involve skin, joints, heart, CNS –Neurologic disease in 15 % of untreated patients Lymphocytic meningitis with episodic headaches Subtle encephalitis with difficult mentation Motor or sensory radiculoneuritis Spinal radicular pain or distal paresthesias Lyme encephalopathy: subtle cognitive disturbances

62. Lyme Disease - Clinical Features (4) Early disseminated disease –Cardiac disease in 5% of untreated patients –Musculoskeletal involvement in 60% of untreated patients Intermittent attacks of joint swelling and pain (knee)

63. Lyme Disease - Clinical Features (5) Late disseminated disease months to years after initial infection Lyme arthritis, neuroborreliosis

64. Lyme Disease – Diagnosis (1) Suspicion based on clinical findings and epidemiology Antibody assays support clinical diagnosis Interpretation of tests can be complicated Make sure the testing lab is approved

65. Lyme Disease – Diagnosis (2) Serologic testing can be negative early –EM may occur before antibody has time to develop –Sensitivity of serology 59% in early LD –Negative serology with EM should not preclude diagnosis

66. Two test approach: –ELISA Antibody test –If ELISA positive, check western blot test. WB: IgG (chronic) and IgM (acute) –IgG + requires 5 bands out of 10 –IgM + requires 2 bands out of 3 Source: Lyme Disease. NEJM, Vol 345, no 2. July 12, 2001 Lyme Disease – Diagnosis (3)

67. Disseminated or late stage : almost always strong IgG response. PCR in joint fluid Titers can persist many years after treatment Lyme Disease – Diagnosis (4)

68. Treatment for Reported Cases, 2009 Treatment% of Cases Doxycycline 65.1 Amoxicillin 12.7 Other 7.7 Unknown 6.6 No Response 7.9 Total 100

69. Lyme Disease – Prevention (1) Avoidance of tick- infested habitat Tick repellent, tick checks

70. Prevention (2) Wear enclosed shoes and light-colored clothing with a tight weave to spot ticks easily If possible, wear long pants and tuck them into the socks Scan clothes and any exposed skin frequently for ticks while outdoors Stay on cleared, well-traveled trails Use insect repellant containing DEET on skin or clothes if you intend to go off-trail or into overgrown areas

71. Prevention (3) Avoid sitting directly on the ground or on stone walls (havens for ticks and their hosts) Keep long hair tied back, especially when gardening Do a final, full-body tick-check at the end of the day (also check children and pets) Upon returning home, clothes can be spun in the dryer for 20 minutes to kill any unseen ticks

72. Prevention (4) To remove a tick, follow these steps (36 hour rule): 1. Using tweezers, grasp the tick by the head or mouthparts right where they enter the skin. DO NOT grasp the tick by the body. 2. Pull firmly and steadily directly outward. DO NOT twist the tick out or apply petroleum jelly, a hot match, alcohol or any other irritant to the tick in an attempt to get it to back out. 3. Place the tick in a vial or jar of alcohol to kill it. 4. Clean the bite wound with disinfectant.

73. Prevention (at home) (5) Keep lawn mowed and edges trimmed. Clear brush, leaf litter and tall grass around houses and at the edges of gardens and open stone walls. Stack woodpiles neatly in a dry location and preferably off the ground. Clear all leaf litter (including the remains of perennials) out of the garden in the fall. Keep ground under bird feeders clean so as not to attract small mammals.

74. Lyme Disease – Prevention (6) Medical Prophylaxis after a tick bite = 200 mg doxycycline IF four criteria are met: 1.deer tick 2.attached for >36 hours 3.within 72 hours of exposure 4.Exposure to high risk area (most of NH)

75. Lyme Disease – Prevention (7) LYMErix vaccine (approved in 1998) 76% effective in preventing clinical LD persons in moderate or high risk areas with “frequent or prolonged exposure” to tick habitat Removed from the market in 2002 New push for research to create a new Lyme vaccine

76. MMWR. May 7, 2004 / 53(17);365-369

77. Questions? Thank you